Long Term Care Application "*" indicates required fields Step 1 of 8 12% PERSONAL INFORMATIONFirst Name*Middle NameLast Name*Email Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Number*Cell NumberDate of Birth* MM slash DD slash YYYY Have you served in the U.S. armed forces?* Yes No If Yes, provide Years of Service:FromToAre you a U.S. citizen?* Yes No Sex* Male Female Marital Status* Married Single Widowed Divorced Separated Name of SpouseReligionHighest Level of EducationOccupationHobbies or Club AssociationsYear Retired FINANCIAL MANAGER PLEASE STATE THE NAME(S) OF ANY PERSON(S) THAT HANDLE FINANCIAL MATTERSNameRelationshipAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneMobile PhoneWork PhoneIs there a Power of Attorney? Yes No Please provide their namePhoneUpload a copy of the power of attorney here Drop files here or Select files Max. file size: 512 MB. Please check type of authority Representative Payee Conservator Legal Guardian Durable Power of Attorney Type: Irrevocable Trust/Bank Account Yes No Funeral HomeContact NameAddressPhone HEALTH CARE PROXY Please upload a copy hereMax. file size: 512 MB.NamePhoneRelationshipAddressIs there a Legal Guardian Yes No Name of Legal GuardianSpokesperson for the ApplicantNamePhone Emergency Contact 1 NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code RelationshipCell PhoneHome PhoneAdd an Emergency Contact Here Health Insurance and Income Medicare #Type of Medicare Part A Part B Part D Part A&B Other Health Insurance You May Have Please Provide a Copy of Your Insurance Card with this ApplicationMax. file size: 512 MB.NamePolicy NumberAre the Premiums Quarterly or Monthly? Monthly Quarterly AmountSocial Security Recipient NameMonthly IncomeRetirement (Pension)Recipient NameMonthly IncomeVA PensionRecipient NameMonthly IncomeRental IncomesRecipient NameMonthly IncomeAnnuitiesRecipient NameMonthly IncomeOtherNameRecipient NameMonthly IncomePlease Note: If you are Applying for Mass health (Medicaid), The look back period is 5 (five) years. This is to determine whether there have been any disqualifying assets transfers. Bank Accounts Bank NameAccount #Names on the AccountTypeBalanceAdd Another Bank Account Here Life Insurance Policy 1 Company NameBeneficiaryPolicy #Face ValueAdd Another Insurance Plan Here Current Living SituationDoes the Applicant Live Alone?* Yes No With Whom Do They Live?AddressContact PersonTelephone #PhysicianTelephone #Does the Applicant Need Help? (Check All that Apply)* Eating Bathing Getting Dressed Does not Need Help Does the Applicant have memory loss?* Yes No What kind? Short Team Long Term Both Does the Applicant Walk? (Check All that Apply)* Independent Uses Cane Uses Wheelchair Is the Applicant Incontinent? (Check All that Apply)* Bladder Bowel Not Incontinent Has the Applicant been diagnosed With Alzhimer's/Dementia?* Yes No Does the Applicant Have Any Behaviors that Are of Concern?* Yes No Please List Them HereApplicant's Physician*Address*Telephone #* Has the Applicant Been Hospitalized Recently?* Yes No HospitalApprox. Date MM slash DD slash YYYY Please Provide Date of Last Physical Exam MM slash DD slash YYYY Has Applicant Ever Been Admitted To A Nursing Home?* Yes No NameAddressDate MM slash DD slash YYYY Has Applicant Ever Been Admitted To A State Hospital or Psychiatric Unit?* Yes No NameAddressDate MM slash DD slash YYYY Alcohol and Tobacco Usage Alcohol Use* Yes No How often? Past Present Past and Present Tobacco Use* Yes No How often? Past Present Past and Present Application Completed By*Date* MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.
